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Partisanship, Dysfunction, and Racial Fears: the New Normal in Health Care Policy?

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Partisanship, Dysfunction, and Racial Fears: the New Normal in Health Care Policy? Health Care Reform at the State and National Level Partisanship, Dysfunction, and Racial Fears: The New Normal in Health Care Policy? James A. Morone Brown University Abstract Partisan politics snarled both the passage and the implementation of the Affordable Care Act (ACA). This essay examines partisanship’seffects on health policy and asks whether the ACA experience was an exception or the new political normal. Partisanship itself has been essential for American democracy, but American institu- tions were not designed to handle its current form—ideologically pure, racially sorted, closely matched parties playing by “Gingrich rules” before a partisan media. The new partisanship injects three far-reaching changes into national health policy: an unprec- edented lack of closure, a decline in the traditional political arts of compromise and bargaining, and a failure to define and debate alternative health policies. We can get a better sense of how far partisanship reaches by turning to state health policies. The highly charged national debate has migrated into some of the states; others retain the traditional politics of compromise and problem solving. There are preliminary indi- cations that the difference lies in the dynamics of race and ethnicity. Keywords Affordable Care Act (ACA), partisanship, race Let me warn you in the most solemn manner against the baneful effects of the spirit of party. The disorders and miseries which result . always distract the public councils and enfeeble the public administration. —George Washington, “Farewell Address,” September 1796 If we are able to stop Obama on this, it will be his Waterloo. It will break him. —Senator Jim DeMint, July 2009 I thank Bradford H. Gray, Carol A. Boyer, and an extraordinary blind reviewer for their immensely helpful comments. And special thanks to David Mechanic for a career full of quiet but inspiring mentoring. Journal of Health Politics, Policy and Law, Vol. 41, No. 4, August 2016 DOI 10.1215/03616878-3620965 Ó 2016 by Duke University Press Downloaded from http://read.dukeupress.edu/jhppl/article-pdf/41/4/827/435312/827Morone.pdf by guest on 25 September 2021 828 Journal of Health Politics, Policy and Law Partisanship is rising in the United States. Congress is more deadlocked than it has been for a century. Deep divisions split the parties, spill into state governments, roil the engaged public, and perhaps (for this is disputed) split the general population (Abramowitz and Fiorina 2013; McAdam and Kloos 2014: chap 1; Mansbridge and Martin 2013). Party affiliation now trumps race, class, and gender in predicting political views and values (Pew Research Center 2012). The consequences appear to echo George Washington’s (1997: 968–69) warning about partisan politics: disordered government and feeble public administration. Party conflict appears especially sharp in health care policy. The battle over the Affordable Care Act (the ACA or Obamacare) is an extreme instance of partisan politics. The legislation passed in 2010 with just one Republican vote in the House and none in the Senate; Republicans took the conflict to the Supreme Court, which narrowly upheld one central provision (the mandate to buy insurance) and sent the authority over another (Medicaid expansion) to state capitals, where the debate continues (National Federation of Independent Business v. Sebelius, 567 U.S. ___, 132 S.Ct. 2566 (2012)). The fight persisted through the elections of 2012 and 2016, bounced back through the courts (with King v. Burwell, 576 U.S. ___ (2015)), profoundly disrupted the implementation of the pro- gram, and continues to blow up in the Republican Congress (which shuttered the government, voted repeal more than fifty times, and con- tinues to harry the program) (Pear 2015). Six years after passage, the debate goes on in Congress, courts, and state capitals and on the hustings. There are almost no precedents in American history for such sustained conflict. While court decisions have set off great national debates, acts of Congress normally settle the issue. The political conflict sparked by the ACA makes health care policy less stable, less predictable, and less effective. In this essay, I ask whether the sustained conflict over the ACA illustrates a new normal for health care policy. Or was it an exceptional case—perhaps complicated by both conservative activism and a backlash against the first black president? I suggest that the United States is poised between these two alternatives—between the new partisanship and a more traditional, pragmatic health policy debate. In the long run, the dif- ference may lie in how American politics—on both the national and the state level—negotiates the emergence of a majority-minority population. In this essay, I anchor our contemporary division by reviewing the rise of American partisanship. Robust party debate is indispensable for democ- racy, but our political system was not designed to handle the kind of conflict we see today. Next I explain what is new about contemporary partisanship. Downloaded from http://read.dukeupress.edu/jhppl/article-pdf/41/4/827/435312/827Morone.pdf by guest on 25 September 2021 Morone - Partisanship, Dysfunction, and Racial Fears 829 I then examine how partisan conflict shapes health care policy. In some ways, the long, loud debate—right down to cries of “socialism”— stretches back seven decades to the Truman administration. In other ways, however, health politics in the Barack Obama years break with the past. The key to weighing continuity versus change lies in the states where governments teeter between the strong partisanship of national politics and traditional interest-group pragmatism. I suggest that the balance between the partisanship and pragmatism may be motivated by the politics of race and immigration. David Mechanic developed a concept that offers some purchase in diagnosing the current state of health care politics: the idea of trust.In Mechanic’s (1998: 661) formulation, trust is “the expectation that insti- tutions and professionals will act in one’s interests.” Mechanic used the concept to explore the tension between professional norms and market forces. The same concept can be applied to governing institutions. Poli- ticians and activists have lost trust in the other party. On the most funda- mental level, the parties differ in their trust of government. Democrats are more likely to trust experts and public officials; Republicans trust markets. And Americans generally trust state government more than federal—at least until race and immigration enter the equation. When issues grow racialized, however, an entirely different framing offers more purchase: moral politics. Immigrant and black communi- ties stir up ancient American fears—of immoral practices and strange (un-American, unacceptable) values that threaten a good society. Histori- cally, the fears and stereotypes are especially powerful in public health politics (Morone 1997, 2003). Contemporary parties mobilize the issue because, for the first time, one party draws the full range of minority groups and the other appeals largely to white Americans. The result appears to yield very different health policy choices in different states. The Roots of Partisan Politics Both the United States and Europe are grappling with what political sci- entist Ira Katznelson describes as an existential crisis in legislative gov- ernment. The American House and Senate, he writes, are so “paralyzed by party divisions, [they] . appear unable to identify and address our most consequential public problems” (Katznelson 2015: 14). Partisanship gives voters a meaningful choice, but the American system was not engineered for intense partisan politics. How dowe balance meaningful choice without undermining the ability to govern? Downloaded from http://read.dukeupress.edu/jhppl/article-pdf/41/4/827/435312/827Morone.pdf by guest on 25 September 2021 830 Journal of Health Politics, Policy and Law The Two Faces of Partisan Politics We get no help if we look back to the Constitution. The founders did not agree on many things, but they were unanimous in rejecting political parties. Benjamin Franklin was so worried about them that he urged the Constitutional Convention to forbid salaries to public officials—the money, he thought, would generate political competition. Washington (1997) spent much of his 1796 “Farewell Address” pleading with Ameri- cans to end the party strife that had already torn up his cabinet and threatened, in his view, the entire republican experiment. James Madison (1788: 1), the most sophisticated of the first-generation thinkers, called contesting factions “the mortal diseases under which popular governments have everywhere perished.” And Thomas Jefferson (1984: 942–43), as usual, managed the most quotable summation, in 1789: “If I could not go to heaven but with a party, I would not go there at all.” Political parties were the only major feature of American governance that was not debated at the Constitutional Convention or among the founding generation. As a result, there is no early conceptual map about their proper role. Although party competition sprang up almost immediately, it took American leaders almost a half century to fully embrace it. When they finally did so, in the 1820s, they illustrated the enduring conundrum of partisanship by identifying two very different dimensions (Hofstadter 1969). On the one hand, the parties were and are the great American engines of democracy. They gave the (white, male) people an unprecedented say over the choices facing the new nation. From thevery start, Americans disagreed about whether they wanted an active, ambitious national government (championed by Washington, Hamilton, and John Adams) or a small and retiring one that deferred to states and individuals (Jefferson, Madison). Factions immediately sprang up around the question. As the factions grew into parties, they became the largest and most sophisticated organizations in the early republic. As they maneuvered for advantage, the parties pushed the franchise to more and more (white, male) voters. Mass political parties championed democracy, offered the voters choices, and became one of the most enduring American contributions to popular government.
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